My App
Schedule Your Demo
Medical Consultation Reports
This document contains a comprehensive collection of medical consultation reports from various patients, documenting evaluations for conditions including renal failure, hypertension, electrolyte imbalances, and other complex medical issues. Each consultation provides detailed patient histories, physical examinations, laboratory findings, impressions, and treatment plans.
Electroencephalogram Report
PATIENT NAME: _____, _____
ELECTROENCEPHALOGRAM:
This is a routine electroencephalogram recording showing background activity consistent of fairly well developed well organized rhythm in the range of 6 to 7 cycles per second of low amplitude. The recording is bilaterally symmetrical high voltage activity in the range of 4 to 5 cycles per second activity lasting from 2 to 3.5 cycles per second intermittently in a generalized pressure without any definite periodicity.
Artifact with EKG and respirator were seen to be _____05:01.
Photic stimulation and hyperventilation were not reviewed.
IMPRESSION: This is abnormal electroencephalogram recording with clinically generalized limited functions with _____05:07 seizures. However, no seizures are noted clinically during the recording.
ABDUL R. MAMSA, M.D.
ARM/atl DD: 09/11/2007 18:38 DT: 09/12/2007 09:15
Consultation for Elevated BUN and Creatinine - Patient: Magnet, Delene
Reason for Consultation
For evaluation of elevated BUN and creatinine.
History of Present Illness
The patient is a 77-year-old Caucasian, nursing home resident, who was brought into the emergency room last night after the patient was found unresponsive with shortness of breath. The patient, in the emergency room, was found at first with a blood pressure of 80/40. He received the administration of IV fluids, consistent of normal saline, at a dose of 500 cc x3 doses. Upon further evaluation, he was found with increased troponin and increased levels of brain natriuretic peptide and a diagnosis of left ventricular dysfunction, most likely associated to ischemia, and heart failure was made. The patient has not diuresed as much despite the administration of Lasix 20 mg on two occasions. Upon further evaluation, he was found with a serum creatinine of 2.9 mg/dL, the reason why this consultation has been prompted.
Key Findings
  • Blood pressure: 80/40 initially, now 110/60 mmHg
  • Serum creatinine: 2.9 mg/dL
  • BUN: 54 mg/dL
  • Troponin: 4.8
  • Brain natriuretic peptide: 2200
Past Medical History
Remarkable for aphasia, history of previous stroke with left-sided hemiplegia, history of hypertension, and hyperlipidemia. The patient is a nursing home resident.
Medications in the Nursing Home
He has been on trazodone, Lipitor, Lopressor, Phenergan, and Percocet.
Impression and Diagnoses
1. Oliguric Acute Renal Failure
Probably multifactorial, rule out hemodynamically mediated glomerular dysfunction secondary to hypotension, versus secondary to decreased cardiac output in the setting of the compensated congestive heart failure, versus septic acute renal failure.
2. Underlying Chronic Kidney Disease
The patient has a baseline serum creatinine between 1.3-1.4 mg/dL. Potential etiologies include hypertension and nephrosclerosis. His estimated glomerular filtration rate is 53 mL/minute.
3. Rule Out Acute Non-Q Wave MI
Rule out acute non-Q wave myocardial infarction.
4. Sepsis Syndrome
Sepsis syndrome with rapid atrial fibrillation.
5. Cardiomyopathy
Cardiomyopathy with left pleural effusion.
6. Rule Out Mediastinal Mass
Rule out mediastinal mass and pericardial effusion.
7. Severe Hypomagnesemia
Severe hypomagnesemia with high anion gap metabolic acidosis.
8. Increased Liver Function Test
Should suspect cholelithiasis versus sharp liver.
Physical Examination Findings
Vital Signs
His blood pressure at this moment is 110/50 and heart rate is 120.
General Appearance
He is awake, alert, but he cannot articulate.
Laboratory Data
Laboratory Determination from Last Night
Cardiac and Metabolic Markers
  • Brain natriuretic peptide: 2200
  • Troponin: 4.8
  • Glucose: 133
  • BUN: 54
  • Creatinine: 2.9
  • Sodium: 132
  • Potassium: 5.0
Additional Laboratory Values
  • Chloride: 99
  • CO2: 17
  • Anion gap: more than 22
  • Albumin: 1.5
  • Alkaline phosphatase: 224
  • AST: 205
  • CPK: 77
Blood Gas Analysis
Blood gas analysis shows pH of 7.47, PO2 of 96, bicarbonate of 17, and lactic acid 3.4.
Complete Blood Count
Hemoglobin is 10, hematocrit 31%, platelets 143,000, and white blood cell count 9.0.
Treatment Plan
The patient has been admitted to the Intensive Care Unit. The patient's blood pressure now is much better. When he was at the emergency room, his blood pressure was 80/40. He was bolused with normal saline, 500 cc on three occasions, receiving a total of 1500 cc of fluid. However, the patient has developed atrial fibrillation with fast ventricular response. He remains clinically with congestive heart failure. A dose of intravenous diuretics has been provided in order to enhance the elimination of free water. Cardiologist has been consulted to follow up on this patient.
1
Step 1: Stabilization
Maintain hemodynamic stability with IV fluids and monitoring
2
Step 2: Diagnostic Testing
Obtain urine electrolytes for quantification of the fraction of excretion of sodium
3
Step 3: Ongoing Management
Monitor closely; no renal replacement therapy needed at this moment
Thanks Dr. _____09:06 for allowing me to participate in the care of this patient. We will follow closely with you.
ELPIDIO A. ABREU, M.D.
EAA/ATL DD: 08/14/2007 12:23 DT: 08/15/2007 04:17
Additional Consultation Reports Overview
This document contains numerous additional consultation reports from Dr. Elpidio A. Abreu, M.D., covering a wide range of nephrology consultations. The reports document evaluations for patients with various conditions including:
Acute Renal Failure
Multiple etiologies including hemodynamically mediated dysfunction, volume depletion, and sepsis-related causes
Chronic Kidney Disease
Various stages and causes including diabetic nephropathy, hypertensive nephrosclerosis, and ischemic nephropathy
Electrolyte Imbalances
Hyponatremia, hyperkalemia, hypomagnesemia, and metabolic acidosis
End-Stage Kidney Disease
Patients on maintenance hemodialysis requiring ongoing management and dialysis continuation
Common Clinical Patterns
Frequent Diagnoses Across Consultations
Throughout the consultation reports, several recurring clinical patterns emerge that demonstrate the complexity of nephrology care:
Renal Complications
  • Acute renal failure with multiple contributing factors
  • Chronic kidney disease progression
  • Fluid overload and decompensated congestive heart failure
  • Electrolyte disturbances requiring careful management
  • Rhabdomyolysis with potential kidney injury
Comorbid Conditions
  • Diabetes mellitus and diabetic nephropathy
  • Hypertension and hypertensive nephrosclerosis
  • Cardiovascular disease and cardiomyopathy
  • Sepsis syndrome and infections
  • Anemia secondary to chronic kidney disease
Treatment Approaches
The consultations consistently emphasize comprehensive management strategies including fluid management, medication adjustments based on renal function, electrolyte replacement, and careful monitoring. Many patients require coordination between nephrology and other specialties including cardiology, infectious disease, and critical care medicine.
Institute Information
Contact Details
Course Enquiry and Schedule Demo
+91-93903 79206
learn@nimct.com
Application Access and Help Desk
+91-93903 79207
admin@nimct.com
Training Related Issues
+91-93903 79207
training@nimct.in
Website
www.nimct.com
Learning Material: www.learn.nimct.in
Schedule a Demo
Visit: https://calendly.com/training-nimct/30min (choose your available time. We will assist you)
Social Media and Resources
  • Youtube channel: https://www.youtube.com/@nimctech
  • Facebook: https://www.facebook.com/profile.php?id=61583079219463&sfnsn=wa
  • Instagram: https://www.instagram.com/nimct_5
  • LinkedIn: www.linkedin.com/in/national-institute-of-medical-coders-and-technology-2a1125391
  • Twitter: https://x.com/nimctech
  • Play Store: https://play.google.com/store/apps/details?id=com.medicalcoderstrainingacademy.learners
  • Linktree: https://linktr.ee/nimct2025